What to do with abnormal LFTs? Andrew M Smith Hepatobiliary Surgeon

Transcription

1 What to do with abnormal LFTs? Andrew M Smith Hepatobiliary Surgeon

2 "it looks like there's something wrong.with your television set. Matt Groenig, creator of The Simpsons

3 Probability of an abnormal screening test result Number of independent tests Probability of abnormal test (%)

4 Normal Bilirubin Metabolism RBC Hb Degraded to Globin + Fe + Bilirubin Bilirubin bound to albumin Hepatocyte Conjugated Bilirubin Diglucuronide Kidney Urobilinogen Portal Vein Urobilinogen Intestine Bilirubin Urobilinogen Stercobilin

5 Liver Function Tests ALT & AST indicate liver cell necrosis ALP indicates cholestasis (may or may not be obstruction) or bone disease Conjugated bilirubin - suggests liver disease Rule 1 Repeat any abnormal tests before action

6 History most important part of the evaluation of the patient with abnormal LFTs

7 Persistence of deranged LFT Full history and assess risk factors Alcohol intake 28 units/21 units Foreign travel, especially medical Rx abroad, IVDU, high risk sexual activity Drug history, including herbal remedies Family history Symptoms - RUQ pain, pruritus, dark urine Signs: SCLD, Ascites=v.compromised liver function

8 Examination Clinical signs - most apparent in alcoholics Palmar erythema Spider naevi Pseudo Cushings Splenomegaly Dupuytrens Clubbing CREST Jaundice, ascites

9 Examination Obstrucutive Jaundice Temp Tachycardic +/- hypotensive cholangitis Cachexia, Virchow s node,clubbing Courvoisier s law If in the presence of jaundice the gallbladder is palpable then the cause of the jaundice is unlikely to be gallstones Murphy s sign Urine 3. Investigate persistently abnormal LFTs 4. Ultrasound scan in most cases is appropriate

10 How to deal with an abnormal GGT Rule 2 Do not check GGT Extremely poor specificity for disease Occasionally may help to follow alcoholics, but there are still problems, such as duct obstruction in pancreatitis

11 How to deal with an abnormal GGT - 2 CONSIDER (before any thoughts of liver disease) Enzyme inducing drugs Alcohol Sporadic elevation of GGT of u/k cause GGT higher in males than females GGT high in neonates and infants

12 Raised GGT in non-hepatic disorder 3 BUPA screen: 15% males exceeded ULN 4% greater than 2 x ULN Non hepatic causes of raised GGT: Obesity Anorexia MI, pancreatic disease, hyperthyroidism Sporadic

13 How to deal with an abnormal GGT - 4 If high GGT persists - requires investigation Elevated GGT may reflect focal liver lesion and hence USS required GGT is elevated in virtually all forms of parenchymal liver disease High sensitivity LOW SPECIFICITY

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15 ALT and AST Debate as to relative merits of ALT & AST ALT more sensitive & specific AST has many non hepatic sources: Myocardium, skeletal muscle Kidney & pancreas Red blood cells No method of differentiating source of AST Rule 3 Use ALT

16 How to deal with an abnormal ALT - 1 History: Alcohol intake Diabetes Drugs: legal/other Transfusion Family & Social history ALT/AST ratio may be useful in alcoholics, since AST > ALT, in contrast to other forms of liver disease

17 How to deal with an abnormal ALT - 2 Examination: Stigmata of chronic liver disease Liver and spleen size Obesity Heart failure

18 Abnormal ALT - 3 Investigations: Prothrombin time, Albumin Hepatitis B and C Autoantibodies & Immunoglobulins Alpha-anti-trypsin / Cu studies Fasting triglycerides, cholesterol, glucose HbA1c Ferritin Ultrasound scan: fat, focal lesions, splenomegaly & cirrhosis

19 Abnormal ALT - 4 Management: Refer: High ALT s ( >250 - phone ) High PT Chronic liver disease Chronic viral hepatitis USS abnormalities Watch: Alcohol Cholesterol/TGL Obese

20 Raised ALT in 1000 s Acute hepatitis (HAV, HBV, HCV, EBV) Severe auto immune hepatitis Drug reaction Secret or accidental paracetamol overdose Liver congestion Gall stones or cholangitis (unlikely) Extreme rarities (Wilsons)

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22 How to deal with an abnormal Alkaline Phosphatase - 1 History Jaundice Pain Weight loss Itch, tiredness, fever, dry eyes etc Alcohol Drugs Bone disease (other sources of enzyme)

23 How to deal with an abnormal Alkaline Phosphatase - 3 Investigations: USS FBC & blood picture, PT Autoantibodies, Immunoglobulins CRP

24 How to deal with an abnormal Alkaline Phosphatase - 4 Management: Refer: Persistent elevation of ALP (4 Bx) Autoimmune liver disease Dilated/obstructed biliary tree Tumours/abscess Watch: Alcohol abuse Drug cause Untreated cardiac failure

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26 How to deal with an isolated abnormal Bilirubin - 1 History: Family history Jaundice Effect of infection, starvation etc Haemolysis Drugs Examination: Splenomegaly

27 Investigations: Bilirubin sample) How to deal with an isolated unconjugated vs conjugated abnormal Bilirubin - 2 (?fasting Blood film, retic count, Coombs test Urinanalysis: negative for Bilirubin No requirement for imaging

28 How to deal with an isolated abnormal Bilirubin - 3 Management: Refer: Haemolytic anaemia Haematologist Watch: Gilbert s (and reassure - 5% population UK) ALT / ALP normal Bili - unconjugated Retic count normal Urine - neg for bilirubin

29 How to deal with a fatty liver History: Incidental finding Alcohol Abdominal pain Diabetes/cholesterol etc 2. Examination: Normal Obese Xanthelasma etc

30 How to deal with a fatty liver Investigations: Cholesterol / HbA1 4. Management: Alcohol counselling Weight reduction Appropriate diet Consider referral

31 Mr Andrew Smith HPB Surgeon Mr Giles Toogood HPB Surgeon Spire Clinic Monday 1800hrs Tuesday 1800hrs Friday 1700hrs Tel: